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Equity & Diversity |
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Request
for Disability Related Accommodations
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| Part I: (To
be completed by Employee) |
| NAME: | DEPT: | WORK PHONE: | ||
| TIME BASE: $ | HRS/WK: | MONTHS/YEAR: | PERMANENT | TEMPORARY |
| JOB CLASS: | JOB TITLE: | SUPERVISOR: | ||
| EXPLAIN NATURE OF DISABILITY: (2 LINES) | PERMANENT | TEMPORARY * |
| * IF TEMPORARY, EXPIRATION DATE AS VERIFIED BY DOCUMENTATION: | ||
| FUNCTIONAL LIMITATIONS: (3 LINES) | ||
| DOCUMENTATION ATTACHED ON NATURE OF DISABILITY | ||
| DOCUMENTATION ON FILE IN OFFICE OF ADA COORDINATOR | ||
| Part II: (To
be completed by Employee & Dean, Director, or Department Designee) |
| ESSENTIAL JOB FUNCTION FOR WHICH ACCOMMODATION IS BEING REQUESTED: |
| ACCOMMODATION REQUESTED (PLEASE BE SPECIFIC) |
| I verify
that the above information is true and correct to the best of my knowledge
and agree to allow this information to be reviewed by the necessary parties
to enable my accommodation. |
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| Employee Signature: ________________________________ | Date:__________ | |
| I acknowledge
that the information above regarding job status and essential job functions
is correct to the best of my knowledge. I also acknowledge that this request
for accommodation is reasonable, within scope of the job tasks assigned
to the employee. |
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| Dean, Director, or Department Designee:______________________ | Date: __________ | ||